| (a) Periods provided for enrollment in and application
for any health benefit plan provided to a large employer group must
comply with the following:
(1) the initial enrollment period for the employees
meeting the large employer's participation criteria must extend at
least 31 consecutive days after the employee's initial date of employment,
or if the waiting period exceeds 31 days, at least 31 consecutive
days after the date the new entrant completes the waiting period for
coverage;
(2) the new entrant who meets the large employer's
participation criteria must be notified of his or her opportunity
to enroll at least 31 days in advance of the last date enrollment
is permitted;
(3) a new entrant's application for coverage is timely
if he or she submits the application within 31 consecutive days following
the initial date of employment, or following the date the new entrant
is eligible for coverage:
(A) in person;
(B) by mail, postmarked by the end of the specified
period; or
(C) in an alternative method normally accepted by the
large employer carrier, including facsimile transmission (fax), email,
or web-based application; and
(4) the large employer carrier must provide an annual
open enrollment period of at least 31 consecutive days.
(b) If dependent coverage is offered to enrollees under
a large employer health benefit plan, the initial enrollment period
for the dependents must be at least 31 consecutive days, with a 31-consecutive-day
annual open enrollment period.
(c) A new employee who meets the participation criteria
of a covered large employer may not be denied coverage if the application
for coverage is received by the large employer carrier not later than
the 31st day after the later of:
(1) the date on which the employment begins; or
(2) the date on which the waiting period established
under Insurance Code §1501.606 (concerning Employee Enrollment;
Waiting Period) expires.
(d) If dependent coverage is offered to the enrollees
under a large employer health benefit plan, a dependent of a new employee
who meets the participation criteria established by the large employer
may not be denied coverage if the application for coverage is received
by the large employer carrier not later than the 31st day after the
later of:
(1) the date on which the employment begins;
(2) the date on which the waiting period established
under Insurance Code §1501.606 expires; or
(3) the date on which the dependent becomes eligible
for enrollment.
(e) A large employer carrier may not exclude any eligible
employee who meets the participation criteria or an eligible dependent,
including a late enrollee, who would otherwise be covered under a
large employer group.
(f) A large employer health benefit plan may not limit
or exclude initial coverage of a newborn child of a covered employee.
Any coverage of a newborn child of an insured under this subsection
terminates on the 32nd day after the date of the birth of the child
unless:
(1) dependent children are eligible for coverage under
the large employer health benefit plan; and
(2) notification of the birth and any required additional
premium are received by the large employer not later than the 31st
day after the date of birth. A large employer carrier may not terminate
coverage of a newborn child if the carrier's billing cycle does not
coincide with this 31-day premium payment requirement, until the next
billing cycle has occurred and there has been nonpayment of the additional
required premium, within 30 days of the due date of the premium.
(g) If dependent children are eligible for coverage
under the large employer health benefit plan, a large employer health
benefit plan may not limit or exclude initial coverage of an adopted
child of an insured.
(h) If dependent children are eligible for coverage
under the large employer health benefit plan, an adopted child of
an insured may be enrolled, at the option of the insured, within either:
(1) 31 days after the an insured is a party in a suit
for adoption; or
(2) 31 days of the date the adoption is final.
(i) Coverage of an adopted child of an employee terminates
unless notification of the adoption and any required additional premiums
are received by the large employer not later than either:
(1) the 31st day after the insured becomes a party
in a suit in which the adoption of the child by the insured is sought;
or
(2) the 31st day after the date of the adoption. A
large employer carrier may not terminate coverage of an adopted child
if the carrier's billing cycle does not coincide with this 31-day
premium payment requirement, until the next billing cycle has occurred
and there has been nonpayment of the additional required premium within
30 days of the date of the premium.
(j) For purposes of this section, "received by the
large employer" within a specified period means that the item(s) must
be postmarked by the specified period.
(k) If a newborn or adopted child is enrolled in a
health benefit plan or other creditable coverage within the periods
specified in this section, and subsequently enrolls in another health
benefit plan without a significant break in coverage, the other plan
may not impose any preexisting condition exclusion with regard to
the child. If a newborn or adopted child is not enrolled within the
periods specified in this section, then in accordance with §26.306(h)
of this title (relating to Exclusions, Limitations, Waiting Periods,
Affiliation Periods, Preexisting Conditions, and Restrictive Riders),
the newborn or adopted child may be considered a late enrollee or
excluded from coverage until the next open enrollment period.
|
| Source Note: The provisions of this §26.305 adopted to be effective March 5, 1998, 23 TexReg 2297; amended to be effective February 2, 1999, 24 TexReg 575; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective May 17, 2017, 42 TexReg 2539 |
